Efficacy and safety of intraoperative intravenous methadone during general anaesthesia for caesarean delivery: a retrospective case-control study.

BACKGROUND: Most patients undergoing caesarean delivery with general anaesthesia require systemic opioid administration. Due to its rapid onset and long duration of action, intravenous methadone may make it suitable for analgesia after caesarean delivery. Intraoperative methadone combined with postoperative intravenous patient-controlled analgesia with fentanyl or morphine has recently been introduced in our unit. METHODS: A retrospective case-control study of 25 patients who had received methadone was performed. Fifty control patients undergoing elective or emergency caesarean delivery were matched for the use of postoperative intravenous patient-controlled analgesia, transversus abdominis plane (TAP) block and regular non-steroidal anti-inflammatory drugs. Exclusion criteria included preoperative neuraxial analgesia or pre-delivery opioid consumption greater than 10 mg of intravenous morphine equivalents. RESULTS: Patients in the methadone group had lower pain scores and were less likely to require intravenous opioid supplementation in the post-anaesthetic care unit (P<0.001). Opioid consumption over 48 h was significantly lower in the methadone group. Delayed discharge from the post-anaesthesia care unit was due to sedation in one patient in the methadone group compared to three control patients in whom it was due to sedation and inadequate analgesia. CONCLUSION: A single intraoperative bolus of intravenous methadone appeared to provide effective analgesia with an acceptable side-effect profile.

Sugammadex in the management of rocuronium-induced anaphylaxis.

Anaphylaxis during anaesthesia is a rare event that in ∼60-70% of cases is secondary to neuromuscular blocking agents. It has been suggested previously that the recent introduction of sugammadex may provide a novel therapeutic approach to the management of rocuronium-induced anaphylaxis. We describe the case of a 33-yr-old female who suffered a severe anaphylactic reaction to rocuronium, presenting with cardiovascular collapse on induction of anaesthesia. After 19 min of traditional management, she was given a bolus of sugammadex 500 mg. This was associated with an improvement in the adverse haemodynamic state. The underlying reasons for this are unclear, but sugammadex may potentially be a useful adjunct in the management of rocuronium-induced anaphylaxis.

Analgesia after caesarean delivery.

As the number of women giving birth by caesarean increases throughout most of the developed world, so too is research into postoperative pain relief for these women. Like most other post-surgical populations, the new mother needs effective pain relief so that she can mobilise early but she also has the added responsibility of needing to care for her newborn baby. There is no 'gold standard' for post-caesarean pain management; the number of options is large and the choice of method is at least partly determined by drug availability, regional and individual preferences, resource limitations and financial considerations. Most methods rely on opioids, supplemented with anti-inflammatory analgesics, nerve blocks or other adjunctive techniques. The aim of this review is to detail commonly used opioid-based methods and to review the evidence supporting non-opioid methods, when incorporated into a multimodal approach to post-caesarean pain management. Areas of promising research are also discussed.

Epidural analgesia for labour in a patient with a neural tube defect.

This report describes the use of epidural analgesia in a patient with a known neural tube defect. The patient had a severe form of spina bifida cystica which had been operated on in childhood. She had a neurogenic bladder but otherwise had preserved neurological function. She had an epidural catheter inserted in early labour; providing effective analgesia for an uneventful birth. This case outlines the severity of the cystica category of neural tube defects, the added anatomical challenges of previous surgery and the difficulties that may arise from the utilization of epidural analgesia. The case demonstrates that epidural analgesia can be utilized despite such a disorder A thorough history and examination are essential, as are the patient's informed consent and knowledge of possible complications.

Management of a parturient with paroxysmal nocturnal haemoglobinuria.

We present the case of a 30-year-old parturient diagnosed in the first trimester of her first pregnancy as having paroxysmal nocturnal haemoglobinuria. Pancytopenia necessitated regular transfusion of blood products. The risks of infection, haemorrhage and thrombosis, in the presence of severe thrombocytopenia, mild neutropenia and prophylactic anticoagulation, posed management challenges. We discuss the pathophysiology of paroxysmal nocturnal haemoglobinuria and the impact of pregnancy on the disorder, particularly on maternal morbidities such as thrombosis. The issues relevant to antenatal and peripartum obstetric, haematological and anaesthetic care for vaginal delivery are considered. Severe thrombocytopenia proved a contraindication to regional techniques and she required general anaesthesia for evacuation of a retained placenta. The post-partum period was complicated by fever and a requirement for blood products. Management of these problems, of prophylactic anticoagulation and subsequent therapy, are discussed.

The efficacy and cost-effectiveness of prophylactic 5-hydroxytryptamine3 receptor antagonists: tropisetron, ondansetron and dolasetron.

There are currently three 5-hydroxytryptamine3 (5-HT3) receptor antagonists available in Australia. In this randomized, double-blind, parallel group study the prophylactic antiemetic effect of a single dose of tropisetron 2 mg, ondansetron 4 mg or dolasetron 12.5 mg was compared after major gynaecological surgery. One hundred and eighteen patients (group T n = 42; group O n = 36; group D n = 40) were evaluated for nausea, vomiting, recovery characteristics and satisfaction for 24 hours postoperatively. A cost-effectiveness analysis was performed. Rescue antiemetic, prochlorperazine 12.5 mg i.m., was given if vomiting occurred more than 10 minutes after arrival in the recovery room. If prochlorperazine was ineffective one hour after administration, droperidol 1 mg i.v. was given. There were no significant differences between groups for the incidence of vomiting during consecutive epochs until 24 hours postoperatively or overall (57%, 75% and 72.5% for groups T, O and D respectively, P = 0.18). The incidence and number of rescue antiementic treatments for nausea or vomiting were similar. The incidence of nausea and the overall and interval nausea scores were similar except for lower "worst nausea" score in group T between 12 and 18 hours (P = 0.02). Recovery times, satisfaction and cost per patient did not differ between groups. We conclude that the risk of postoperative nausea and vomiting remained high in this setting despite 5-HT3 receptor antagonist prophylaxis and that the choice between these agents should be based on the lowest available acquisition cost.

Assessment of wound infiltration with bupivacaine in women undergoing day-case gynecological laparoscopy.

BACKGROUND AND OBJECTIVES: The effectiveness of local anesthetic wound infiltration for treatment of postoperative pain appears to be variable and partly dependent on the surgical procedure. Although evidence was lacking, it was common practice at our institution to infiltrate the trocar wound of patients undergoing day-case laparoscopic procedures with long acting local anesthetic agents. The aim of this study was to investigate the analgesic efficacy, and the influence of the timing, of local anesthetic infiltration into surgical wounds for day-case diagnostic gynecological laparoscopy. METHODS: A double-blind, randomized trial was conducted on 100 women having general anesthesia for day-case gynecological laparoscopy. Ninety-two patients who had been randomized to 1 of 4 groups for trocar wound infiltration with 30 mL of 0.25% bupivacaine or saline either before or after surgery completed the study. Incisional pain, pain on pressing the umbilicus, severity of nausea, and patient satisfaction with anesthetic technique were all assessed postoperatively until discharge and on the following day through a telephone interview. A P value of <.05 was considered significant. RESULTS: There was no difference between groups in the mean pain scores or analgesic requirements for incisional pain, pain on pressing firmly on the umbilicus, or for patient satisfaction. There was a trend for those patients who had received bupivacaine to use less postoperative morphine (P =.079). CONCLUSIONS: Wound infiltration with local anaesthetic did not significantly reduce pain or opioid requirement after gynecological laparoscopy.

Patient-controlled spinal analgesia for labour and caesarean delivery.

Continuous spinal anaesthesia has not been widely used in Australia. Epidural anaesthesia is often inadequate in patients with previous spinal surgery, as distribution of local anaesthetic in the epidural space is unpredictable. Two cases are presented where continuous spinal anaesthesia enabled satisfactory analgesia and anaesthesia to be obtained for labour and caesarean delivery respectively.

The effect of intravenous ketorolac on opioid requirement and pain after cesarean delivery.

Nonsteroidal antiinflammatory drugs, including ketorolac, are widely used for postoperative analgesia. This randomized, double-blinded trial compared IV ketorolac or saline combined with meperidine patient-controlled epidural analgesia (PCEA) after cesarean delivery. Fifty healthy parturients scheduled for elective cesarean delivery under combined spinal-epidural anesthesia received PCEA plus either IV ketorolac (Group K) or saline (Group C) for 24 h. The ketorolac dose was modified, after six patients had been studied, based on new product information recommending a maximum of 120 mg ketorolac over 24 h. Group K (n = 24) and Group C (n = 20) were demographically similar. During the first 24 h, Group K used significantly less meperidine (P < 0.05). Postoperative pain at rest and with movement, and patient satisfaction, did not differ significantly between groups, except that worst pain at 12 h was less in Group K (P < 0.005). The two groups were similar with respect to patient recovery and side effects. IV ketorolac, as an adjunct to PCEA after cesarean delivery, produced a meperidine dose-sparing effect of approximately 30%, but did not significantly improve pain relief, reduce opioid-related side effects, or change patient outcome.

A portable, disposable device for patient-controlled epidural analgesia following Caesarean section: evaluation by patients and nurses.

Twenty patients undergoing elective Caesarean section were provided with a pethidine-primed disposable Go Medical epidural infuser for postoperative pain control. Patients and nurses evaluated the device by completing a questionnaire. The infuser delivered adequate analgesia, was easy to understand and use, provided the patients with control over their pain relief and allowed good mobility The nursing staff found the device easy to prime and understand, the only drawback being the occasional incidence of equipment failure. The patients expressed a high level of satisfaction with the device and all would use it again if offered the chance. We conclude that the Go Medical epidural infuser is a safe and effective device as used in the postnatal ward setting.

Patient-controlled epidural analgesia in labor: the addition of clonidine to bupivacaine-fentanyl.

BACKGROUND AND OBJECTIVES: Epidural clonidine has not been evaluated as a component of patient-controlled epidural analgesia (PCEA) solutions during labor. A randomized, double-blind trial was conducted to investigate the efficacy and side effects of PCEA using bupivacaine and fentanyl, with or without clonidine. METHODS: Seventy-five healthy parturients in active labor were assigned to a PCEA solution of 0.0625% bupivacaine and fentanyl 2 microg/mL (4 mL demand bolus, 15 min lockout), with or without clonidine 4.5 microg/mL. The primary outcome measure was parturient rating of analgesia; others assessments included pain scores, drug utilization, supplementation and side effects. RESULTS: Thirty-one parturients received clonidine (group BFC) and 38 received control solution (group BF). Eight (6 group BF, 2 group BFC, P = .28) failed to achieve satisfactory epidural analgesia. There was a trend for parturient ratings of pain relief to be higher in group BFC, with significantly more reporting excellent first-stage analgesia (81% v. 57%, P<.05). Pain scores were similar. Clonidine (median dose, 28 microg/h) reduced total bupivacaine and fentanyl use (P<.01), and reduced supplementation (P<.01). Maternal blood pressure (BP) and recordings of systolic BP below 100 mm Hg did not differ. Group BFC had higher sedation scores (P<.01), but no one appeared oversedated. Shivering was reduced in group BFC (P<.01). CONCLUSIONS: The addition of clonidine to epidural bupivacaine and fentanyl for PCEA in labor improved analgesia, reduced the supplementation rate, and reduced shivering. Increased sedation and lower BP were not clinically important.

Postoperative intraspinal opioid analgesia after caesarean section; a randomised comparison of subarachnoid morphine and epidural pethidine.

A randomised, blinded clinical trial was performed to evaluate intraspinal opioid analgesic techniques after caesarean section. Healthy term parturients having elective caesarean section under combined spinal-epidural anaesthesia were allocated to one of three groups. Postoperative analgesia, including non-steroidal anti-inflammatory drugs, was provided using either pethidine patient-controlled epidural analgesia (group PCEA) or subarachnoid morphine 200 microg, the latter supplemented as required with patient-controlled intravenous pethidine (group SMPCIA) or oral paracetamol and codeine (group SMO). Maternal analgesia, side effects, recovery and satisfaction were assessed for 48 h. Of 144 parturients enrolled, 137 completed the study (PCEA n = 44, SMPCIA n = 45, SMO n = 48). The groups were demographically similar. All participants experienced good pain relief, including median visual analogue pain scores (0-100) with movement <40 between 0-24 h. However, pain scores were significantly lower at 8 and 12 h in those receiving subarachnoid morphine (P< 0.05). Women in groups receiving subarachnoid morphine experienced more severe pruritus (P<0.001), nausea (P< 0.001) and drowsiness (P< 0.05). Postoperative recovery of bowel function and ambulation occurred earlier in those using PCEA, although this did not appear to be of clinical significance. Patient satisfaction was similar, although women in group SMO were least likely to choose this approach again (P<0.05). We concluded that all three techniques provided effective analgesia for a prolonged period postoperatively. Better pain relief, but more opioid-related side effects, resulted from subarachnoid morphine 200 microg, and re-evaluation of reduced doses of subarachnoid morphine may be warranted.

The antiemetic and dysphoric effects of droperidol in the day surgery patient.

The incidence of side-effects of two doses of droperidol used as a prophylactic antiemetic were compared (10 vs 20 micrograms/kg). Two hundred and twenty-eight women for day case laparoscopy were recruited. Pain and nausea scores were collected in the recovery area and in the Day Surgery Unit prior to discharge. A telephone follow-up questionnaire was administered. Incidences of anxiety, restlessness and dysphoric reactions were similar in both groups (29.2% vs 29.0%). The incidence of postoperative vomiting varied from 4.4 to 7.7%. There were no significant differences between the two groups when nausea scores, incidences of vomiting and pain after discharge were compared. An unexpected finding was the significantly higher incidence of pain in the 10 micrograms/kg group. We conclude that there is no advantage in lowering the dose of droperidol below 20 micrograms/kg in this group of patients.

Postoperative nausea and vomiting: development of a management protocol.

Postoperative nausea and vomiting (PONV) is still an important and common problem. Despite the introduction of new antiemetic drugs, the management of PONV remains difficult. In this article we describe the development and evaluation of a management protocol for PONV, which consists of a treatment algorithm accompanied by a nursing education program. Implementation of this management protocol has been well-accepted by staff, appears to have reduced delay in patient treatment and improved patient care, and has significantly reduced staff workload. It is planned to use continuous quality improvement techniques to further refine the algorithm and continue assessment of its efficacy and of patient satisfaction.

Maternal experience during epidural or combined spinal-epidural anesthesia for cesarean section: a prospective, randomized trial.

UNLABELLED: Epidural anesthesia (EA) and combined spinal-epidural anesthesia (CSEA) are popular anesthetic techniques for elective cesarean section. A randomized, blind study was conducted to compare maternal experiences during these regional anesthetics. EA was established using alkalinized 2% lidocaine with epinephrine and fentanyl, whereas spinal anesthesia was performed using 2.5 mL hyperbaric 0.5% bupivacaine and fentanyl via a single-space CSEA approach. Both patients and observers were blinded to the anesthetic technique allocation. One hundred twenty patients were enrolled; 6 were withdrawn (Group EA, n = 55; Group CSEA, n = 59). Of the two techniques, CSEA was associated with earlier onset times (P < 0.001), more intense motor block (P < 0.05), and greater ephedrine use (P < 0.01). Anxiety was significantly lower (P < 0.05) and satisfaction was higher (P < 0.05) before starting surgery with CSEA. Pain scores were lower pre- and intraoperatively with CSEA, a difference that became significant during block placement and at delivery (P < 0.05). There were no differences between groups in the incidence or severity of hypotension and nausea or analgesic supplementation rate; or for postoperative assessments of intraoperative pain, anxiety and satisfaction, and postpartum backache and headache. We conclude that maternal conditions and experience were good with both methods, although CSEA conferred several minor advantages. IMPLICATIONS: Epidural and combined spinal-epidural anesthesia are often used for elective cesarean sections. Although the combined spinal-epidural anesthetic technique conferred minor advantages, both techniques were associated with low anesthetic failure rates, good operative conditions, and high maternal satisfaction levels.

Postoperative epidural infusion: a randomized, double-blind, dose-finding trial of clonidine in combination with bupivacaine and fentanyl.

The aim of this randomized, double-blind trial of postoperative thoracic epidural analgesic infusions was to determine whether clonidine at 10 microg/h (group C10, n = 22), 15 microg/h (Group C15, n = 24), or 20 microg/h (Group C20, n = 24) improved postoperative analgesia in patients undergoing abdominal gynecologic surgery, without side effects or hemodynamic changes, when added to a 5-mL/h infusion of 0.125% bupivacaine and fentanyl 2 microg/mL (Group CO, n = 22). The 24-h study infusion was supplemented, as required, by patient-controlled epidural fentanyl. Groups were similar for age, weight, duration, and type of surgery. Clonidine produced a dose-dependent improvement in analgesia at rest. Only 20 microg/h significantly increased the percentage of patients who experienced no pain with coughing (relative risk 1.44, 95% confidence interval 1.24-1.94), reduced pain scores with coughing (P < 0.05), and significantly lowered supplementary fentanyl requirements (P < 0.05). Groups were similar for sedation, pruritus, nausea, time to ambulation, and satisfaction with analgesia. Clonidine produced a dose-dependent decrease in blood pressure and pulse rate and an increase in vasopressor requirement (P < 0.01). Epidural clonidine infused at 20 microg/h improves analgesia during coughing when combined with epidural bupivacaine-fentanyl in patients undergoing lower abdominal surgery but is associated with hemodynamic changes and increased vasopressor requirement.

Patient-controlled epidural analgesia following caesarean delivery: a comparison of pethidine and fentanyl.

Pethidine and fentanyl have both been used to provide patient-controlled epidural analgesia (PCEA) following caesarean delivery. Both have been compared with epidural morphine but these drugs have not been compared with each other. Patient-controlled epidural analgesia was used in a prospective, randomized, double-blind, cross-over trial to compare fentanyl and pethidine for postoperative epidural analgesia in women having elective caesarean deliveries. Two groups received either PCEA fentanyl or pethidine with a cross-over to the other drug after 24 hours. Results from 45 patients showed no difference in pain level outcomes, but pethidine scored better in all side-effects except for drowsiness at 48 hours. Patients were more satisfied with pethidine (P = 0.015) and overall 65% of patients preferred pethidine. We conclude that pethidine is a suitable drug for patient-controlled epidural analgesia and leads to greater patient satisfaction than does fentanyl.